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Thread: Medicare as secondary.. still has to approve?

  1. #1

    Medicare as secondary.. still has to approve?

    Getting a new wheelchair (possibly hopefully) so I figured this was the best forum for it. Maybe some of you know if I?m off base here.

    Basically i have private insurance as primary through my job, BCBS. I also still have Medicare cuz I just came off of SSDI a few months ago. But for sure that means BCBS is primary and Medicare is secondary.

    My intellectually disadvantaged DME tried to switch my TR to an Aero T (without telling me) because they said Medicare would deny the titanium frame. I said that?s fine, let them deny the hair and move forward with BCBS. Now they?re saying they can?t do this because they will go to prison if they don?t charge Medicare and therefore if Medicare doesn?t approve the TR they won?t order it.

    what the hell?

    that can?t be right, right? I mean I get my meds without ever billing Medicare, is my pharmacy gonna to to jail for that?

    surely they are just full of it and don?t know what they?re doing, Right?

    i was working with another company and they had the order ready to go charging just BCBS in 3 months. Then I found out they were out of network. I?ve been working with the incompetence of NSM for 15 months and now they?re trying to tell me I can?t have a titanium chair.

    Its super frustrating to me because if I have to go back to the first company I?ve waisted a year and a half for no reason and I also have to pay an extra 20% copay which is gonna be another $1000 out of pocket or so.

  2. #2
    Senior Member Oddity's Avatar
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    You're in what's called a "coordination of benefits" scenario. The rules are varied. Start here to educate yourself a bit. Medicare might still be primary, but you'll have to research via CMS a bit for authentic/knowledgeable advice.

    https://www.medicare.gov/supplement-...#collapse-2437
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

  3. #3
    Medicare is definitely secondary, I work for a big huge corporation and I am no longer getting disability. Even my current DME says they’re secondary.

  4. #4
    Ti lite lists the TR vs Aero T frame weight difference as 9 vs 14 pounds. My shoulders are already giving me hell, I don’t need to lug any extra weight in and out if the car six times a day.

  5. #5
    Senior Member NW-Will's Avatar
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    I feel your pain.

    I really wish there was a definitive place to go to find info about how this works. Every DME and PT I speak to act as though it's voodoo and there is some grand wizard somewhere making these decisions and no one is truly certain how it works.

    It seems like it's in everyone's interests but ours to keep this process and rules as obfuscated as possible to keep us in the dark. (similar to how real estate agents like to think of themselves!) And like real estate, we do this so infrequently, you don't do it enough to know the intricacies of the rules, my favorite quote is, "Oh it's all changed from the last time you got a chair!"

    Where are DME's going for information that they use for these arbitrary decisions? I say arbitrary as it seem different DME's and PT's have different interpretations. Find the right combination and you have GOLD!

  6. #6
    In my last DME battle, I called Medicare and badgered people up the food chain until someone agreed to write me a “benefits clarification letter” which I then took to the DME provider and suddenly they shut up and did work. Best wishes.

  7. #7
    My understanding is that Original Medicare disallows titanium upgrades but Medicare Advantage may approve it. I don't understand why. But I am being told it has something to do with fraud control.

  8. #8
    Senior Member Oddity's Avatar
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    Quote Originally Posted by funklab View Post
    Medicare is definitely secondary, I work for a big huge corporation and I am no longer getting disability. Even my current DME says they?re secondary.
    Then your DME is wrong. You aren't limited by what Medicare will or won't cover if they aren't primary. By telling them to file Medicare first THEN BCBS you may have inadvertently given them the impression Medicare is primary. If they're insisting on filing Medicare first, then they definitely have this misconception. Get the documentation from CMS, Benefit Coordination Center, explaining Medicare pays second in your case, and stick it under their nose. They sound ignorant or willfully deceptive (as if the Aero T via Medicare has a better margin for them than the TR via BCBS).
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

  9. #9
    In that case, the primary may pass along the 20% copay to Original Medicare who may deny it completely leaving the entire 20% copay to the member. Medicare Advantage shouldn't do that.

  10. #10
    Senior Member Oddity's Avatar
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    He doesn't have Medicare Advantage. That's basically an HMO contracted to coordinate benefits for a Medicare enrollee, using the HMO's benefit package (as long as it meets minimum requirements). Whether, or not, an Advantage plan will reimburse for a titanium chair is entirely up to them, and different plan to plan.

    His primary BCBS plan probably doesn't have the same 80/20 co-pay. It's just a traditional large group plan via his employer.

    There really is no reason to continue to carry (and pay for) Medicare coverage, as secondary, other than to maintain continuing coverage, and avoid the 2 year wait in the future if he wants to go back on SSDI and Medicare only IMO.
    "I have great faith in fools; self-confidence my friends call it." - Edgar Allen Poe

    "If you only know your side of an issue, you know nothing." -John Stuart Mill, On Liberty

    "Even what those with the greatest reputation for knowing it all claim to understand and defend are but opinions..." -Heraclitus, Fragments

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